GW1-2023-00912_Well Construction - GW1_20230120

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WELL CONSTRUCTION RECORD(GW-1), For Internal Use Only:` �q�-E� � �.+1.Well Contractor Information: ° ` G E ��h
Landon Phillips `..
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14:WATER ZONES
i Well Contractor Name FAOi1i TO DESCRIPTION
I. 3441A Cbs fL 170 ft. L//) I+i40ra�a i�f Prr�
Ct. fL f(WDOG
NC Well Contractor Certification Number
15i OUTER CASING ifor multi-cased wells OR LINER if a licable
i NW Poole Well and Pump Company FROM TO DIAI/tETER TIIICKNESS aiATERLIL
Company Name
rt. ft. in.
16.INNER CASING OR TUBING eothermal closed-too
2.Well Construction Permit#: ,(� FROM TO DIAMETER TfIICKNESS MATERIAL
Last all applicable yell construction permits(i.e.UIC,County,State,Variance,etc..) ft. ft. in.
3.Well Use(check well use): ft. I ft. I1n.
I
Water Supply Well: 17;SCREEN
I
❑AgriculRual ❑Municipal/Public
FROM I TO DIAMETER SLOTSIZE THICKNESS MATERUL ft. rt. in.
i ❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. tt. In
❑Iidustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
[]Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EAIPLACE51ENT METHOD&AMOUNT
Nou-Water Supply Well: Ct. ft. (7� �t1
❑Monitoring ❑Recove
IY ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salmi Barrier 19.SAND/GRAVEL PACK(if air licable
h' FROM. TO 11IATI AL E11fPLACEI1fENTaIETIIOD
❑Aquifer Test ❑StormwaterDrainage
❑Experimental Technology ❑Subsidence Control
❑Geotlnennal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soiVrock a min size etc.)
I ft. Irr. U 5 i`C
4.Date Well(s)Completed:
Z Well ID# ft. ft. C (/
5a.Well Location': J1 ' ft. ft.
Cs'f C 040 m bof'r� ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
[OC)3 3cow:`.nj pllce ycnrA ijk IV6 ft. _ ft.
Physical Address,City,and Zip ft. ft.
21.REMARKS
iII Comity U Parcel Identification No.(PIN)
5b.Latitude anti longitude in degrees/niinutes/seconds or decimal degrees:
(ifwell Geld,one hullong is sufficient) ' 22.Certificat•
N 2
'I 6.Is(are)the vvell(s): ®Permanent or ❑Temporary Signature of Certified Well Contractor ` Date
By signing this form,'hereby certtry that the mell(s))vas(were)constructed in accordance iridr
7.Is this a repair to an existing well: ❑Yes or 8No 15A NCAC 01C.0100 or 1SA NCAC 01C.0100 1i'el/Cottstrtctioit Sraitdards and altar a cop'•
1(dnis is a repair,fill out known well construction information and explain the nature ofthe ofdds record has been provided to the well owner.
repair under g21 remarks section or o»the back of this form.
23.Site diagram or additional well details:
I S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may also attach additional pages if necessary.
drilled: i
n(� 24..SUBN=AL INSTRUCTIONS
I 9.Total well depth below laird surface:
Far multiple wells list all deptlts,fdierent(exantple-3@200'and 2@100� ( ) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
1(waler tenet is above casltrg,use"+ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
it 11.Borehole diameter: (in,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(RUC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 24c.For Water Supply and Open-Loon Geothermal Return \'ells:Copy to the
(i.e.auger,rotary,cable,direct push etc.) county environmental healtin department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells Droducine over 100 000 GPD Copy to DWR,CCPCUA
13a.1'ield(gpm) Method of test BIOW Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 1 lb.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources _Revised 6 6-2018